Here was my situation when diagnosed in 2012. The CT showed the tumor in the head of the pancreas very close to the portal vein. The surgeon said I had a small window of opportunity and he was prepared to do the Whipple the next morning-a Saturday. I was at a high -volume center in NYC and my surgeon at that time had done over 1500 Whipple surgeries and in addition performed liver transplants so he was trained as a vascular surgeon and proficient at handling vascular involvement.

When I was open up and examined, it was noted the tumor was in contact with the portal vein. A portal vein resection was done and the surgical pathology revealed the tumor had penetrated completely through the vascular wall. A week after the Whipple, a post surgical CT was done and found metastatic disease was present. It was not seen two weeks prior because it was too small to be detected and the resolution of a CT in 2012 was about 4-5mm whereas today it is 1.3mm. So because I just had surgery, I had to wait 8 weeks to heal to begin chemotherapy. That meant no treatment of the metastatic disease and to make things even worse, when I did get chemo, I had no response to the first chemo regimen.

Had I been in the position to have neoadjuvant chemo and assuming I would have received Folfirinox, it likely would have addressed the micrometastatic disease when it is easier to treat. Neoadjuvant chemo has shown better outcomes. I could not do neoadjuvant even if was available in 2012 because the compression of the bile duct and the close proximity of the tumor to the portal vein made the situation “time is of the essence”. I was fortunate in the outcome of now being an 11 year survivor and N.E.D. after having stage IV disease. It required 46 cycles of adjuvant chemo with 24 cycles of full-dose Folfirinox and 22 cycles of 5-FU/Leucovorin in alternating groups of six cycles every 15 days for 24 months with no pause. It makes me wonder if I would have needed that much chemo to knock out the disease and achieve N.E.D. had neoadjuvant chemo been a possibility for me?